Job Description
Job Description
The role is open to telework!
As the Clinical Pharmacy Manager you will:
* Provide direct supervision and support to the clinical pharmacist prior authorization/Coverage Determination review team, Quality Analysts, and Pharmacy Technician leadership team
* Oversee end-to-end Coverage Determination, Prior Authorization, and Appeals processes for Medicare-Medicare Plans (MMPs) and Mercy Care Advantage.
* Ensure all CMS, State, and NCQA compliance requirements are met.
* Conduct robust internal auditing to ensure compliance and contractual requirements are met.
* Meet or exceed all monthly turnaround time requirements (>99%).
* Hire, coach, and train staff members including pharmacists and pharmacy technicians.
* Implement process improvements that increase efficiency and reduce errors.
* Work closely and cultivate relationships with matrix partners (e.g., Health Plan Leadership, Case Management, Quality).
* Liaise with Health Plan Pharmacy Directors to deliver excellent customer service to the Health Plans and membership.
* Fully support and present cases during internal and external (CMS, NCQA, NORC, OIG) audits.
* Prepare and submit CMS, State, and compliance-required reporting each month.
* Meet all health plan contractual requirements for completing prior authorization reviews within
Required Qualifications
- 5+ years pharmacy experience
- Current unrestricted state pharmacy license
-Strong analytical, communication and customer service skills.
-Ability to use standard corporate software packages and corporate applications.
Preferred Qualifications
-Managed Care experience
-Medicare and/or Medicaid experience
-Managerial experience in leading large diverse teams
-Process improvement/optimization experience
Education
Doctor of Pharmacy (Pharm.D.) or equivalent
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
The role is open to telework!
As the Clinical Pharmacy Manager you will:
* Provide direct supervision and support to the clinical pharmacist prior authorization/Coverage Determination review team, Quality Analysts, and Pharmacy Technician leadership team
* Oversee end-to-end Coverage Determination, Prior Authorization, and Appeals processes for Medicare-Medicare Plans (MMPs) and Mercy Care Advantage.
* Ensure all CMS, State, and NCQA compliance requirements are met.
* Conduct robust internal auditing to ensure compliance and contractual requirements are met.
* Meet or exceed all monthly turnaround time requirements (>99%).
* Hire, coach, and train staff members including pharmacists and pharmacy technicians.
* Implement process improvements that increase efficiency and reduce errors.
* Work closely and cultivate relationships with matrix partners (e.g., Health Plan Leadership, Case Management, Quality).
* Liaise with Health Plan Pharmacy Directors to deliver excellent customer service to the Health Plans and membership.
* Fully support and present cases during internal and external (CMS, NCQA, NORC, OIG) audits.
* Prepare and submit CMS, State, and compliance-required reporting each month.
* Meet all health plan contractual requirements for completing prior authorization reviews within
Required Qualifications
- 5+ years pharmacy experience
- Current unrestricted state pharmacy license
-Strong analytical, communication and customer service skills.
-Ability to use standard corporate software packages and corporate applications.
Preferred Qualifications
-Managed Care experience
-Medicare and/or Medicaid experience
-Managerial experience in leading large diverse teams
-Process improvement/optimization experience
Education
Doctor of Pharmacy (Pharm.D.) or equivalent
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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